Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
22 items
1 source
8 inquiries
Source spread
Where this theme appears
Care risk assessment failures has been flagged across 1 independent accountability source:
22 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (22)
R95 — Blue light protocol for at-risk registers
Recommendation: HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent the person having to leave their home in the community.
Response Pending
R82 — Risk-based inspection prediction
Recommendation: RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service …
Response Pending
R68 — Cumulative risk assessment across protection plans
Recommendation: Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also …
Response Pending
R35 — Inpatient facilities on risk register
Recommendation: Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs should automatically place any inpatient facility or facility for people with challenging behaviour on its risk register.
Response Pending
R25 — Pressure damage risk assessment
Recommendation: Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score.
Gov response: Section 4.1 of the Scottish Government's response addresses this by stating that the prevention and management of pressure ulcers is a fundamental aspect of nursing practice. Healthcare Improvement Scotland published a Best Practice Statement - …
Accepted
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Prior to the publication of the Inquiry's report, DBT agreed that instead of a nine-month period for postmasters to submit a full appeal there should be a three-month deadline to notify the Department of an …
Accepted
POH-12 — Amend GLOS to allow claimants oral submissions at panel hearings
Recommendation: The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by …
Gov response: Department for Business and Trade accepts this recommendation. GLOS claimants already had the right to make oral submissions for up to one hour at independent panel hearings prior to the panel making a binding determination. …
Accepted
57 — Distinguish CSE risk from actual exploitation
Recommendation: The Department for Education and the Welsh Government must ensure that their updated national guidance makes clear that signs that a child is being sexually exploited must never be treated as indications that a child is only 'at risk' of …
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
No update 2+ yrs
R101 — Whole-system commissioning with cross-agency risk assessment
Recommendation: Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a …
Response Pending
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
SP22 — LCC online harms risk assessment review
Recommendation: Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff …
Gov response: The Department for Education (DfE) is taking responsibility for this recommendation in place of the Department for Health and Social Care and expects to complete implementation of this recommendation by mid-2026. Progress and next steps: …
Accepted
In progress
SP2 — Shared multi-agency risk-assessment tool
Recommendation: Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public sector services.
Gov response: The government agrees with all 67 recommendations made by the Chair. The government recognises these five fundamental failings. These failings are unacceptable. The Chair has made 10 recommendations for issues to be considered further by …
Accepted
In progress
WATE-(46) — Prohibit emergency admissions to all private residential schools
Recommendation: Emergency admissions should not be made to private residential schools.
Unknown
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
JB-15.4 — Amend firearms authorisation forms for risk assessment and tipping points
Recommendation: There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to …
Gov response: MPS formally responded on 28 October 2022 (paras 12-14). Internal guidance issued to CTSFO Tac Advisors within MO19 on tailoring FA5 forms. Training time set aside for FA form usage and completion.
Accepted
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
R7 — Reorganisation due diligence
Recommendation: In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.
Gov response: Section 2.2 of the Scottish Government's response describes the 'Governance for Quality Healthcare in Scotland - an Agreement' and a 'clinical and care governance framework for integrated health and social care services' to ensure good …
Accepted
JB-15.2 — Require multidimensional risk assessments throughout operations
Recommendation: Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Gov response: MPS formally responded on 28 October 2022 (paras 7-8). Firearms trainers required to watch Inquiry hearing recordings. Particular focus now on multidimensionality at all stages of operational planning. MO19 supporting College of Policing on improved …
Accepted